75 yo with slow progression 1 y after FOLFOX/bev -> 5-FU/bev?


75 yo with slow progression 1 y after FOLFOX/bev -> 5-FU/bev?

What systemic treatment would you most likely recommend for the following patients:

A 75-year-old patient with asymptomatic mCRC responds to FOLFOX/bevacizumab but develops peripheral neuropathy. Oxaliplatin is stopped and the patient continues on 5-FU/bevacizumab with good treatment tolerance but after 1 year develops slow, minimally symptomatic disease progression on imaging and the peripheral neuropathy has still not resolved. The tumor is KRAS wild type.

Same patient as above, but the tumor is KRAS mutant?

Steven R Alberts, MD, MPH
Chair, Division of Medical Oncology
Professor of Oncology
Mayo Clinic
Rochester, Minnesota
Answer: FOLFIRI alone; FOLFIRI alone

For a 75-year-old asymptomatic patient with KRAS wild-type or mutant mCRC and unresolved peripheral neuropathy, I would probably administer FOLFIRI alone.

Al B Benson III, MD
Professor of Medicine
Associate Director for
Clinical Investigations
Robert H Lurie Comprehensive
Cancer Center of
Northwestern University
Chicago, Illinois
Answer: FOLFIRI + bev or irinotecan + bev; FOLFIRI + bev

For a 75-year-old patient with asymptomatic KRAS wild-type disease, I would consider treatment with either FOLFIRI/bevacizumab or irinotecan/bevacizumab.

I would consider administering FOLFIRI and bevacizumab to this 75-year-old patient with asymptomatic KRAS-mutant mCRC.

Charles S Fuchs, MD, MPH
Director
Center for Gastrointestinal Cancer
Dana-Farber/Harvard Cancer Center
Professor of Medicine
Harvard Medical School
Boston, Massachusetts
Answer: FOLFIRI + bev; FOLFIRI + bev

For a 75-year-old patient with KRAS wild-type or mutant mCRC, I would stop treatment with oxaliplatin if the peripheral neuropathy has not resolved. I would treat with FOLFIRI/bevacizumab. I have treated other diseases with aflibercept on clinical trials but I’ve not used it for colon cancer yet.

Richard M Goldberg, MD
Professor of Medicine
Physician-in-Chief, OSUCCC -
James Cancer Hospital and
Richard J Solove Research Institute
Klotz Family Chair in Cancer Research
The Ohio State University
Columbus, Ohio
Answer: FOLFIRI + bev; FOLFIRI + bev

I would administer FOLFIRI in combination with bevacizumab to a 75-year-old asymptomatic patient with KRAS wild-type mCRC.

For a 75-year-old asymptomatic patient with KRAS-mutant disease, I would likely administer FOLFIRI in combination with bevacizumab. However, I might start with a reduced dose of irinotecan for the first cycle.

Axel Grothey, MD
Professor of Oncology
Department of Medical Oncology
Mayo Clinic
Rochester, Minnesota
Answer: FOLFIRI + bev; FOLFIRI + bev

For a 75-year-old asymptomatic patient with KRAS wild-type or mutant mCRC, I would administer FOLFIRI/bevacizumab because this patient survived after receiving FOLFOX/bevacizumab as initial therapy.

Howard S Hochster, MD
Associate Director (Clinical Research)
Yale Cancer Center
Professor of Medicine
Yale School of Medicine
New Haven, Connecticut
Answer: Irinotecan + cetuximab; Irinotecan + bev

For a 75-year-old asymptomatic patient with KRAS wild-type mCRC, I would opt for irinotecan in combination with an EGFR antibody. I would choose cetuximab over panitumumab because I have used it for a longer period.

For a 75-year-old patient with KRAS-mutant mCRC, I would switch to irinotecan/bevacizumab. I would consider treatment with aflibercept. However, because we have no data on cross resistance and I am not sure whether it’s more efficacious than bevacizumab beyond progression, I don’t tend to use aflibercept.

Herbert I Hurwitz, MD
Associate Professor of Medicine
Division of Hematology/Oncology
Clinical Director, Phase I Program
Co-leader, GI Oncology Program
Duke University Medical Center
Durham, North Carolina
Answer: FOLFIRI + panitumumab or FOLFIRI + bev; FOLFIRI + bev or FOLFIRI + aflibercept

For a 75-year-old patient with wild-type disease, I would opt for FOLFIRI and the EGFR antibody panitumumab. My second treatment choice would be FOLFIRI/bevacizumab because this patient was well enough to have received FOLFOX-based therapy in the first place. However, I might adjust the dosage.

If the 75-year-old asymptomatic patient with KRAS-mutant disease were well enough to have initially received FOLFOX/bevacizumab, I would administer FOLFIRI/bevacizumab as my first treatment choice. My next choice would be FOLFIRI/aflibercept.

Wells A Messersmith, MD
Professor and Director
GI Medical Oncology Program
Co-Leader
Developmental Therapeutics Program
University of Colorado Cancer Center
Aurora, Colorado
Answer: FOLFIRI + cetuximab; FOLFIRI + bev

For a 75-year-old patient with asymptomatic, KRAS wild-type mCRC, I would administer FOLFIRI/cetuximab. I believe in switching over to an EGFR monoclonal antibody for a patient with KRAS wild-type disease instead of continuing bevacizumab beyond disease progression.

If this patient had KRAS-mutant mCRC, I would administer FOLFIRI/bevacizumab.